Initial bladder closure of the cloacal exstrophy complex: Outcome related risk factors and keys to success (original) (raw)
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Journal of Pediatric Urology, 2018
Introduction: Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods. Objective: The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure. Study design: The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012-2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications. Results: Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999-2010, delayed closure was performed more frequently in this cohort (71% vs 27%).
Journal of Pediatric Surgery, 2017
Background/Purpose: The aims of surgical management in cloacal exstrophy (CE) have shifted to optimizing outcomes and quality of life while minimizing morbidity. This report reviews the single-institution experience of complications of bladder closure in CE. Methods: Patients with CE were identified from a prospectively-maintained bladder exstrophy-epispadias complex database. Operative and follow-up data were analyzed to compare complications and failure rates of bladder closure between closures performed with and without osteotomy and primary versus reoperative closures. Results: Of 134 patients followed with CE, 112 met inclusion criteria. Median follow-up time was 3.05 years. The failure rate among 112 primary closures (mean age 8.4 months) was 31.3% versus 51.9% in reoperative closures (mean age 19.7 months) (p=0.044). Complication rate among primary and reoperative closures was 17.9% and 33.3%, respectively (p=0.076). For closures with pelvic osteotomy, failure rate was 24.0% versus 45.9% without osteotomy (p=0.018). Among primary closures with osteotomy, the complication rate was 21.3% versus 10.8% without osteotomy (p=0.171). Conclusions: Complications of bladder closure are common in CE. Pelvic osteotomy reduces failure rates without a significant rise in complications, which are often minor. There was no statistically significant difference in complication rates between reoperative and primary closures. However, reoperative closures were more likely to fail, emphasizing the importance of a successful primary closure.
Failed exstrophy closure: Management and outcome
Journal of Pediatric Urology, 2010
Objective: In a series of failed exstrophy closures, to identify determinants of successful repeat closure and the impact of failed closure on the fate of the lower urinary tract and continence status. Patients and methods: We performed a retrospective review of operative notes and medical records of patients with a history of one or more failed exstrophy closures in 1978e2007. The primary surgical endpoints were failure rate of repeat closure attempts, mode of continence surgery and continence outcome. Continence was defined as achieving a dry interval of >3 h and voiding through the urethra. Results: We identified 122 patients (85 male/37 female) who had undergone repeat closure following failure. The success rate of repeat closure attempts at our institution was 98%.
Bladder Neck Closure in Children: A Decade of Followup
The Journal of Urology, 2009
Purpose: Bladder neck closure necessitates lifelong clean intermittent catheterization. Concerns have been raised regarding well-being and compliance in patients on long-term clean intermittent catheterization. Noncompliance may result in subsequent hydronephrosis, incontinence, infection, cystolithiasis and perforation. We analyzed our long-term results with bladder neck closure followed at least 10 years for patient compliance with clean intermittent catheterization, upper tract preservation, continence, complications and subsequent procedures. Materials and Methods: All patients followed at least 10 years after bladder neck closure were included in this study. Results: Seven boys and 5 girls with a mean age of 7.0 years and urinary incontinence underwent bladder neck closure and continent urinary diversion between 1993 and 1998. The primary diagnosis was exstrophy in 5 patients, spinal dysraphism in 3, trauma in 2, sacral agenesis in 1 and a duplicated hindgut in 1. Mean followup was 12.4 years (range 10 to 14). All patients performed clean intermittent catheterization 4 to 6 times daily. Hydronephrosis improved or remained stable in the 11 patients who underwent bladder augmentation. Mild new hydronephrosis developed in 1 patient and resolved after increasing clean intermittent catheterization frequency. Bladder neck closure successfully cured incontinence in all of the last 6 patients who underwent modified bladder neck closure with a posterior bladder neck flap, while 2 of the earlier 6 bladder neck closures required revision for a subsequent 100% success rate. Additional operations were required in 6 patients. To our knowledge this is the longest followup after bladder neck closure reported in the literature. Conclusions: Patient compliance with long-term clean intermittent catheterization is good after bladder neck closure. Bladder neck closure provides excellent long-term safety for the upper urinary tract and continence. It is associated with relatively low morbidity, which is correctible.
Bladder Neck Closure in Children: A Decade of Followup. Commentary. Author's reply
The Journal of Urology, 2009
Purpose: Bladder neck closure necessitates lifelong clean intermittent catheterization. Concerns have been raised regarding well-being and compliance in patients on long-term clean intermittent catheterization. Noncompliance may result in subsequent hydronephrosis, incontinence, infection, cystolithiasis and perforation. We analyzed our long-term results with bladder neck closure followed at least 10 years for patient compliance with clean intermittent catheterization, upper tract preservation, continence, complications and subsequent procedures. Materials and Methods: All patients followed at least 10 years after bladder neck closure were included in this study. Results: Seven boys and 5 girls with a mean age of 7.0 years and urinary incontinence underwent bladder neck closure and continent urinary diversion between 1993 and 1998. The primary diagnosis was exstrophy in 5 patients, spinal dysraphism in 3, trauma in 2, sacral agenesis in 1 and a duplicated hindgut in 1. Mean followup was 12.4 years (range 10 to 14). All patients performed clean intermittent catheterization 4 to 6 times daily. Hydronephrosis improved or remained stable in the 11 patients who underwent bladder augmentation. Mild new hydronephrosis developed in 1 patient and resolved after increasing clean intermittent catheterization frequency. Bladder neck closure successfully cured incontinence in all of the last 6 patients who underwent modified bladder neck closure with a posterior bladder neck flap, while 2 of the earlier 6 bladder neck closures required revision for a subsequent 100% success rate. Additional operations were required in 6 patients. To our knowledge this is the longest followup after bladder neck closure reported in the literature. Conclusions: Patient compliance with long-term clean intermittent catheterization is good after bladder neck closure. Bladder neck closure provides excellent long-term safety for the upper urinary tract and continence. It is associated with relatively low morbidity, which is correctible.
The Journal of Urology, 2001
Purpose: The surgical repair of bladder exstrophy remains challenging for the pediatric urologist. We present our preliminary experience with complete primary repair of exstrophy in neonates and children with failed initial closure. Materials and Methods: Between November 1998 and April 1999, 9 boys and 2 girls with bladder exstrophy underwent complete repair. This procedure was performed in the first 72 hours of life in 4 boys and at age 3 months in 1 girl. Complete repair with osteotomy was performed after failed initial closure in 5 boys and 1 girl at a mean age of 28 months (range 15 to 36). The bladder and urethra were closed in continuity and epispadias was repaired by total penile disassembly. All patients were kept in a spica cast for 3 weeks. Ureteral stents and suprapubic tube were removed 10 and 14 days, respectively, after surgery. Ultrasound was performed preoperatively and every 3 months postoperatively, voiding cystourethrography was done 6 to 12 months after surgery.
International braz j urol
Kelly´s Together Project (KTP) is a great initiative. The results of this work may bring very important information to the Pediatric Urologists community. The opportunity to treat a relatively high number of OIES cases, including complex patients with a single and standardized technique is unique. The number of patients tends to be high because of Brazilian´s territorial scope and big population, where legal abortion is prohibited. The availability of the National Brazilian Health Service facilitates logistics.
Osteotomy for Bladder Exstrophy: Commentary and Ten Tips for Success
Journal of the Pediatric Orthopaedic Society of North America, 2020
Patients with Bladder Exstrophy, though rare, are cared for at most Children's Hospitals. Although osteotomy is not always needed for closure, especially in the neonatal period, it can significantly increase the success treating those presenting late. Specific indications for osteotomy, as part of a reconstruction include wide diastasis as seen in cloacal exstrophy, re-closure after failed initial repair, patients with persistent abnormal perineal appearance, and uterine prolapse due to a wide pelvic floor.
Primary Bladder Exstrophy Closure in Neonates: Challenging the Traditions
The Journal of Urology, 2014
Purpose: We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy. Materials and Methods: We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test. Results: A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p ¼ 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were 42,732forpatientsadmittedtotheintensivecareunitand42,732 for patients admitted to the intensive care unit and 42,732forpatientsadmittedtotheintensivecareunitand16,214 for those admitted directly to the surgical ward (p <0.0001). Conclusions: Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization. Abbreviations and Acronyms BE ¼ bladder exstrophy CBEX ¼ classic bladder exstrophy ICU ¼ intensive care unit